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r APPLICATION FOR PERMIT �J r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health DistrictT l�jr �(11 �. j/J f �� i c/� DiXS_/`Iy F Job Address / City Lot Size PM Owner's Name Address /43 a4 . Phone / ; Contractor Address License No. Phone aCl� TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE 6-F WiLL"—0k_0BLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca x Dia. of Well Excavation - Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications �} * Public ❑ Other ❑ DeltaDepth of Grout Seal Type of Grout _ I I Irrigation _..Approx.'Depth l I Eastern- Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material atop 50'1 Depth Filler Material !Below 50'l l TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RFPAIR/ADDITION l i DESTRUCTIO (No septic system permitted if public sewer is ' { vailable within 200 feet.) i Installation will serve: Residence_ Commercial Other Number of living units: ' Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance toynearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size Y _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - v I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin Local Health Di"%trict. e' l Home owner or licensed agent's signature'certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif 0." The applica s II f all re ui e i c ete drawing on reverse side. Signed X Title: Date: /1 FOR DEPARTMENT USE ONLY Application Accepted by _ �L% Date ` a( Area Pit or Grout Inspection by Date Final Inspection by Date w Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621; ❑ Manteca 823-7104 -❑ Tracy, 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .. �' i INFO FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT�NO. t -�- EH 11.28(REV.J%K51 i �.� e o /3 S